Hemotympanum as a Complication of a Valsalva Maneuver during Childbirth

Background Hemotympanum may occur due to otic barotrauma secondary to Valsalva maneuver during the second phase of labor. A pressure differential across the tympanic membrane (TM) of about five psi can cause rupture. The increased intrathoracic and intraabdominal pressure spikes repeatedly manifested by “pushing” during second-stage labor easily approach (and may exceed) this level. Clinical Presentation. This case report describes a healthy thirty-seven-year-old multipara patient admitted for the 40-weeks' gestational age routine follow-up that proceeded to active labor followed by an aural fullness and bloody otorrhea. Otoscopic examination with a light microscope confirmed the hemotympanum of the right tympanic membrane. Conclusion Forceful Valsalva can cause hemotympanum. Investigating the benefits and disadvantages of the pushing methods could help reduce such complications in the future. A prompt evaluation of an otolaryngologist should be requested in the event of a new postpartum hearing disturbance or bloody otorrhea.


Background
Hemotympanum is defned by the presence of blood in the middle ear cavity that corresponds to purple discoloration or ecchymosis of the TM.
A common cause of hemotympanum is barotrauma [1]. During active vaginal delivery, the woman is "pushing the baby out," performing repeated Valsalva maneuvers [2] (further referred to as Valsalva), which can eventually increase middle ear pressure and cause barotrauma. Perforation of the TM due to Valsalva has been reported in association with delivery [3]. Described here is a case of labor-induced hemotympanum, which has not been reported in the English literature to the best of our knowledge.
Hemotympanum can occur for various reasons such as temporal bone fracture due to blunt trauma, fracture of the external auditory canal, ossicular trauma, middle ear barotrauma [4], therapeutic nasal packing, epistaxis [5,6], blood disorders, anticoagulation therapy, and otitis media.
Hemotympanum presents as the presence of blood in the middle ear cavity or ecchymosis of the TM, which leads to conductive hearing loss, thus the need to perform an audiogram. Patients with hemotympanum commonly complain of otalgia, tinnitus, and aural fullness [1].
Te management of hemotympanum is conservative, but antibiotics may be prescribed for infection prophylaxis.

Clinical
Presentation. An otherwise healthy, thirtyseven-year-old multipara, G3P2, presented to the emergency ward at 40 + 0 gestational weeks in active delivery. Her pregnancy was remarkable for an increased alphafetoprotein and an abnormal glucose challenge test; however, amniocentesis, a brain-directed fetal ultrasound (US), and a glucose tolerance test were found normal. She had no recorded history of otolaryngologic procedures or complaints and no recent barometric pressure changes.
During the obstetric examination, her vital signs, aside from elevated blood pressure, were unremarkable, with a low Bishop score (a prelabor scoring system assisting in predicting whether labor induction would be required). Te fetal parameters, including weight and movements, confrmed by the fetal US, were within normal limits. Due to gestational age, multiparity, and elevated blood pressure with patient consent, membrane-stripping was performed to induce labor.
Te patient preferred avoiding labor augmentation and was transferred to the delivery room to support natural childbirth. Te delivery proceeded uneventfully, without anesthesia or analgesia, until reaching a normal third stage. Without a need for an episiotomy, a healthy boy has been delivered, weighing 4234 grams with an APGAR score of 9/ 10. Te placenta was delivered spontaneously and was intact. Te patient has received routine postpartum uterine stimulants.
After childbirth, the patient noticed aural fullness and hearing loss in her right ear. Shortly after noticing these symptoms, she was referred to the otolaryngology resident for prompt examination. During anamnesis, she denied earache, tinnitus, or dizziness. During the examination, spontaneous right-ear frm otorrhea was seen, like a blood clot blocking the medial portion of the external canal. No previous head trauma or complaints of concurrent earache, facial nerve palsy, tinnitus, or dizziness were registered. Since the resident assumed that the otorrhea was a blood clot, a hydrogen peroxide solution toilette was initiated and suctioned to clear the external ear canal. After several attempts to clean the external ear canal, the microscope otoscopy exam still revealed that the medial part of the external ear canal was obstructed. For this reason, she was advised to repeat the exam the following day if her symptoms did not improve.
On the follow-up exam, the patient was examined by a diferent ENT resident. Te patient complained only of aural fullness. Microscope otoscopy displayed a bulgy purple mass covering the whole diameter of the TM without noticing perforation or fresh bleeding (Figure 1). After a thorough examination and consultation, complete with an anterior rhinoscopy and right-leaning Weber examination, she was diagnosed with hemotympanum secondary to childbirth. Te patient was instructed to perform a complete audiogram and reevaluation the next day; however, she did not return. Further documentation from a community follow-up showed no additional reports of a hemotympanum.

Discussion
Te TM is a 1 cm diameter half-transparent, oval-shaped membrane which separates the external ear from the middle ear. It consists of three layers: the outer layer stratifed squamous keratinized epithelium; the middle layer lamina propria; and the inner layer simple cuboidal epithelium. Te lamina propria contains the blood vessels of the tympanic membrane [7].
In 1963, Tornhill described the hemotympanum as a "blue eardrum" since it was caused by the presence of blood in the middle ear [8]. Te defnition of hemotympanum is the presence of blood in the middle ear cavity that corresponds to purple discoloration or ecchymosis of the TM. Common causes of hemotympanum are temporal bone fractures, therapeutic nasal packing, epistaxis, blood disorders, anticoagulant therapy, otitis media, and barotrauma.
While no similar cases of labor-induced hemotympanum were found in the English written literature, Baum et al. reported a TM perforation following the intrapartum Valsalva maneuver [3].
A possible causing mechanism could be ear barotrauma, created by unequalized pressure diferentials between the middle and external ears [9].
Ear barotrauma can be caused during fying, diving, and aggressive Valsalva [6,9], a forceful attempt of acceleration against a closed airway, performed to equalize pressure across the TM and open the Eustachian tubes during changes in the ambient pressure.
When barotrauma occurs, as in aggressive Valsalva, the created vacuum leads to an increase in the blood fow of the subcutaneous vessels of the TM and blood engorgement, which can cause serous efusion. Should the pressure continue to rise without equalization of the middle ear, it will result in traumatic injury to the TM and middle ear and consequent rupture of the TM blood vessels into or behind the TM, also known as hemotympanum.
Attention is needed following hemotympanum since the accumulation of blood in the middle ear may lead to conductive hearing loss (CHL). Hemotympanum is managed conservatively [10], but antibiotics may be prescribed for infection prophylaxis. However, Becker and Parell note that prophylactic antibiotics and decongestants have not been proven helpful in the case of barotrauma [11].
While mostly harmless, hemotympanum might lead to ossicular chain disruption or fxation, mainly of the IS joint, due to residue formation, hyalinization, as well as ischemic necrosis of the long process of the incus, as it is a watershed area. While no reported study has been performed on these theorized connections, it might be prudent to follow-up with audiological and otological examinations.
Te forceful Valsalva maneuver also afects the inner ear, which may lead to persistent hearing loss due to inner ear hemorrhage, tinnitus due to an intracochlear membrane tear, and dizziness due to a perilymph fstula [12].
Te Eustachian tube is an essential component of ambient pressure equalization. Its dysfunction is common during pregnancy due to the increased mucosal edema, causing obstruction and otitis media with efusion [13,14]. Tus, pregnancy may lead to ear pressure function abnormalities and predisposition to barotrauma.
Te second stage of labor, in which the cervix is fully dilated, is considered the pushing stage, which is critical for the baby's head to navigate through the maternal pelvis. In this stage, the woman is guided to perform the Valsalva pushing maneuver by taking a deep breath at the beginning of the contraction, holding her breath (closed glottis), and pushing as long and as hard as she can, along with uterine contractions [15]. Tis contrasts with the "physiological pushing" when the woman directly pushes in response to an involuntary urge with an open glottis without taking a deep breath frst [2].
Caldeyro-Barcia postulated [16] that closed glottic pushing infuences maternal hemodynamics and increases Similarly, in the current case report, the Valsalva pushing maneuver during the second stage of delivery led to an increased intrathoracic or intraabdominal pressure with a consequent elevation of the venous pressure in the head and neck areas, presumably causing the rupture of the tympanic membrane capillaries and the ecchymoses. Te baby's size could also play a role in such an event, as in the present case, the newborn was 4234 g which is above the 95th percentile weight for male babies [18] and might have led to a greater efort while pushing.
Other possible explanations include masked coagulation disorder, a vascular cause such as an arterial aneurysm, as described by Horowitz et al. [19], or tympanomastoid or jugular paragangliomas [20], that both can lead to a hemorrhage and bloody otorrhea. In addition, while not probable, it could be that the hemotympanum was an unrelated occurrence.

Conclusions
Pushing during labor can afect remote and small areas of our body, such as the retina and the tympanic membrane. It is not clear if our patient used the Valsalva pushing or the physiological pushing, but either way, it was forceful enough to cause hemotympanum, as described here. A prompt evaluation of an otolaryngologist should be requested in the event of a new postpartum hearing disturbance or bloody otorrhea.

Data Availability
Any additional information can be obtained by contacting the main author.

Disclosure
Tis case report is based on a patient that was hospitalized at the hospital I work.

Conflicts of Interest
Te authors declare that they have no conficts of interest.